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Background: The national health care response to coronavirus (COVID-19) has varied between countries. The United Kingdom (UK) and the Netherlands (NL) have comparable maternity and neonatal care systems, and experienced similar numbers of COVID-19 infections, but had different organisational responses to the pandemic. Understanding why and how similarities and differences occurred in these two contexts could inform optimal care in normal circumstances, and during future crises. Aim: To compare the UK and Dutch COVID-19 maternity and neonatal care responses in three key domains: choice of birthplace, companionship, and families in vulnerable situations. Method: A multi-method study, including documentary analysis of national organisation policy and guidance on COVID-19, and interviews with national and regional stakeholders. Findings: Both countries had an infection control focus, with less emphasis on the impact of restrictions. Differences included care providers’ fear of contracting COVID-19; the extent to which personalised care was embedded in the care system before the pandemic; and how far multidisciplinary collaboration and service-user involvement were prioritised. Conclusion: We recommend that countries should 1) make a systematic plan for crisis decision-making before a serious event occurs, and that this must include authentic service-user involvement, multidisciplinary collaboration, and protection of staff wellbeing 2) integrate women’s and families’ values into the maternity and neonatal care system, ensuring equitable inclusion of the most vulnerable and 3) strengthen community provision to ensure system wide resilience to future shocks from pandemics, or other unexpected large-scale events.

Background\ud Midwifery Led Care (MLC) has shown to be beneficial for women and for midwives. The implementation of MLC remains challenging.\ud \ud Objective\ud To explore the utility of MLC and midwives’ behavioural determinants.\ud \ud Methods\ud A systematic mixed-methods review was conducted, integrating data derived from methodologically different studies into a single mixed-methods synthesis. Data were organized using the Feasibility–Appropriateness–Meaningfulness–Effectiveness (FAME) scale. Behavioural MLC determinants were grouped in an extended Attitude–Social influence–Self-efficacy (ASE) model. After a synthesis and summary of the data and a descriptive thematic analysis, all FAME/ASE variables were quantified for a Bayesian Pearson correlation analysis.\ud \ud Results\ud The relationships between the FAME scales and ASE themes showed very strong evidence (BF 31.1–41.6), strong (BF 11.2–28.5) and to a lesser degree moderate (BF 3.1–9.7), and anecdotal evidence (BF 1.5–2.9). MLC utility was predominantly explained by the appropriateness and effectiveness of MLC and their correlations with the midwife’s attitude, the perceived social influence of the public, supportive factors, regulation, professional and personal norms, and intention.\ud \ud Conclusion\ud To implement, scale up, and maintain MLC, a multipronged approach is needed. Midwives need to stand up for their professional identity in the wider culture and climate of maternity services to push the change for MLC.

The aim of this prospective longitudinal study was to examine the association between Cesarean section (CS) and child development and behavior. The sample consisted of 256 children who were born at term without serious perinatal pathologies. Their development and behavior was assessed at the age of four using Ages and Stages Questionnaire (ASQ-3), Children’s Behavior Questionnaire and Strength and Difficulties Questionnaire. Multivariate linear regression analyses were conducted to assess the association between CS and child outcomes. CS was associated with better scores in the Problem Solving domain of the ASQ in the whole sample. After stratifying by child sex, the positive association between CS and the Problem Solving domain was significant in boys, while no association was found in girls. Girls were rated less optimally in the Gross Motor domain of the ASQ when born via CS. Mode of birth was not associated with behavioral outcomes. Electronic supplementary material The online version of this article (10.1007/s10578-020-01084-4) contains supplementary material, which is available to authorized users.

Prevention of mother-to-child transmission programs have been one of the hallmarks of success in the fight against HIV/AIDS. In Brazil, access to antiretroviral therapy (ART) during pregnancy has increased, leading to a reduction in new infections among children. Currently, lifelong ART is available to all pregnant, however yet challenges remain in eliminating mother-to-child transmission. In this paper, we focus on the role of near-infrared (NIR) spectroscopy to analyse blood plasma samples of pregnant women with HIV infection to differentiate pregnant women without HIV infection. Seventy-seven samples (39 HIV-infected patient and 38 healthy control samples) were analysed. Multivariate classification of resultant NIR spectra facilitated diagnostic segregation of both sample categories in a fast and non-destructive fashion, generating good accuracy, sensitivity and specificity. This method is simple and low-cost, and can be easily adapted to point-of-care screening, which can be essential to monitor pregnancy risks in remote locations or in the developing world. Therefore, it opens a new perspective to investigate vertical transmission (VT). The approach described here, can be useful for the identification and exploration of VT under various pathophysiological conditions of maternal HIV. These findings demonstrate, for the first time, the potential of NIR spectroscopy combined with multivariate analysis as a screening tool for fast and low-cost HIV detection.

Key points1 Maternity services across Europe during the pandemic has undergone changes to limit virus transmission; however, many changes are not evidence-based.2 Although these changes were introduced to keep women, babies and healthcare staff safe, the exclusion of companions and the separation of mothers and babies is particularly antithetical to a human rights-based approach to quality care.3 A poll of COST Action 18211 network members showed that inconsistency in the application of restrictions was high, and there were significant deviations from the recommendations of authoritative bodies.4 Concerns have emerged that restrictions in practice may have longer term negative impacts on mothers and their families and, in particular, may impact on the long-term health of babies.5 When practice changes deviate from evidence-based frameworks that underpin quality care, they must be monitored, appraised and evaluated to minimise unintended iatrogenic effects.

• The COVId-19 pandemic is associated with an increased prevalence of depression and anxiety in the perinatal period \ud • It is imperative to prioritise the processes for early recognition, referral, and treatment of pregnant women with mental illness \ud • There is a need for further research to identify potential protective and risk factors for mental illness in the perinatal period, especially during the pandemic

The United Nations Sustainable Development Goals 2030 aim to reduce health care inequity and maternal and infant mortality rates amongst marginalized populations. To provide adequate and culturally relevant maternity care for minority ethnic groups, it is imperative to examine health care providers' views on care for migrant women. We reviewed published accounts of views and experiences of maternity health care providers providing maternity care for migrant women as a way of exploring their cultural competency. A qualitative meta-synthesis was conducted. Systematic searches were conducted in five electronic databases from inception dates through February 2021. Qualitative data were analyzed using a framework thematic analysis based on Campinha-Bacote's five-component cultural competency model. Eleven studies were included. Findings were presented according to Campinha-Bacote's model: cultural awareness, cultural knowledge (personal responsibility, familial role and cultural influence, the influence of social and system factors, conflicting maternity care expectations), cultural encounter (language and communication), and cultural desire (establishing trust and going the extra mile, resources to boost culturally competent care). Our findings can inform the design of high-quality behavioral change, health care management, sociological, and other relevant studies, along with reviews of what matters to service users about cultural responsiveness. Our data also suggest that health system constraints can exacerbate the lack of cultural competency. Improving the quality of care for migrant communities will necessitate a joint effort between health care organizations, health care providers, policymakers, and researchers in developing and implementing more culturally relevant maternity care policies and management interventions. [Abstract copyright: © 2021 Wiley Periodicals LLC.]

BACKGROUND: The purpose of this study is to report on the validation process of the Spanish version of a questionnaire that explores health science students’ attitudes towards women’s childbirth experiences. This questionnaire could help inform education programs to enhance the quality of woman-professional interactions, and to improve women’s experiences of childbirth. \ud \ud METHODS: A standardised procedure for the development and validation of the questionnaire included: item development and psychometric pre-validation, Cronbach’s Alpha and split-half coefficients calculation, test–retest and item-total correlation for the reliability analysis. Content validity was undertaken by Delphi method with sixteen panelists over two rounds. We determined the factor structure and refined and validated the questionnaire according to the responses of a cohort of 160 students using principal components factor analysis with varimax rotation. \ud \ud RESULTS: A 52-items questionnaire CAVE-st: (acronym for cuestionario de actitudes sobre vivencias y experiencias en el parto) was developed and validated. The questionnaire had a high construct validity, with a Cronbach´s alpha > 0.92. The intraclass correlations (0.80) indicated adequate test–retest reliability. The results of the exploratory factor analysis revealed fourteen latent components that explained more than the 70% of the observed total variance.\ud \ud CONCLUSIONS: The Spanish version of the questionnaire CAVE-st has been developed and validated. Its psychometrics indicate that it is a valid and reliable tool to assess health sciences students’ attitude towards women´s childbirth experience. Further work to translate and adapt the instrument in other cultures and languages will be undertaken.

The early post-natal period is a critical period in women's infant feeding journeys, often marked by high levels of unintended breastfeeding cessation. Previous research has argued that infant feeding should be perceived within a complex system whereby factors operating at different ecological levels (i.e., individual, social/community networks, cultural/institutional) interact to affect individual behaviors. However, currently, more work needs to be done to implement an ecological approach in breastfeeding programs. We adopted a complex-systems lens approach to explore how multi-level factors—individual, mother-infant dyad, health service, family and social networks, and wider community infrastructure—interacted with women's motivations and experiences of breastfeeding. We undertook a secondary analysis of 24 women's interviews; all the women had a strong antenatal intention to breastfeed and were expecting their first baby. The interviews were collected during the UK-based Assets-based feeding help Before and After birth (ABA) feasibility trial when their infant was aged between 4 and 21 weeks. Categorical content analysis was used to explore the interrelationships between key factors and to identify different infant feeding typologies. Two different typologies emerged: “disappointed” (n = 7) and “by hook or by crook” (n = 17). “Disappointed” women had stopped breastfeeding early; women classified as “by hook or by crook” continued breastfeeding despite facing challenges. Sociodemographic, social, and service level differences between the typologies were noted. “Disappointed” women were more likely to be younger, White-British, to have considered mixed-feeding antenatally and experienced negative breastfeeding support from healthcare professionals and personal networks. Infants of “disappointed” women were more likely to have received unexpected “top-ups” and to be perceived as having infant feeding difficulties. Women classified as “by hook or by crook” were just as likely as “disappointed” women to experience birth-related complications, but demonstrated more proactive help-seeking behaviors, had positive experiences of personal/professional support and accessed wider support. While further research is needed to consolidate and/or refute the typologies, the ecological approach shifts the focus away from mothers' decisions to consider the multi-level factors that need to be in place to enable women to breastfeed successfully. Further work to encourage help-seeking behaviors and toward improving facilities, support, and services is needed.

Introduction A positive childbirth experience promotes women’s health, both during and beyond the perinatal period. Understanding what constitutes a positive childbirth experience is thus critical to providing high-quality maternity care. Currently, there is no clear, inclusive, woman-centered definition of a positive childbirth experience to guide practice, education, and research. Aim To formulate an inclusive woman-centered definition of a positive childbirth experience. Methods A six-step process was undertaken: (a) Key concepts associated with a positive childbirth were derived from a rapid literature review; (b) The key concepts were used by interdisciplinary experts in the author group to create a draft definition; (c) The draft definition was presented to clinicians and researchers during a European research meeting on perinatal mental health; (d) The authors integrated the expert feedback to refine the working definition; (e) A revised definition was shared with women from consumer groups in six countries to confirm its face validity; and (f) A final definition was formulated based on the women’s feedback (n = 42). Results The following definition was formulated: “A positive childbirth experience refers to a woman’s experience of interactions and events directly related to childbirth that made her feel supported, in control, safe, and respected; a positive childbirth can make women feel joy, confident, and/or accomplished and may have short and/or long-term positive impacts on a woman’s psychosocial well-being.” Conclusions This inclusive, woman-centered definition highlights the importance of provider interactions for facilitating a positive childbirth experience. Feeling supported and having a sense of control, safety, and respect are central tenets. This definition could help to identify and validate positive childbirth experience(s), and to inform practice, education, research, advocacy, and policy-making. CC BY-NC-ND 4.0Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)© 2022 The Authors. Birth published by Wiley Periodicals LLC.First published: 05 July 2022Correspondence Julia Leinweber, PhD, RM, Institute of Midwifery, Charité - University Medicine Berlin, Oudenarder Strasse 16, 13347 Berlin, Germany. Email: julia.leinweber@charite.de

Background Caesarean sections (CS) in Bangladesh have risen eight-fold in the last 15 years. Few studies have explored why. Anecdotally, physicians suggest maternal request for CS is a reason. Women and families suggest physicians influence their decision-making. The aim of this research was to understand more about the decision-making process surrounding CS by exploring physician–patient communication leading to informed-consent for the operation. Methods We conducted a mixed-method study using structured observations with the Option Grid Collaborative’s OPTION5 tool and interviews with physicians and women between July and December 2018. Study participants were recruited from eight district public-sector hospitals. Eligibility criteria for facilities was ≥ 80 births every month; and for physicians, was that they had performed CSs. Women aged ≥ 18 years, providing consent, and delivering at a facility were included in the observation component; primigravid women delivering by CS were selected for the in-depth interviews. Quantitative data from observations were analysed using descriptive statistics. Following transcription and translation, a preliminary coding framework was devised for the qualitative data analysis. We combined both inductive and deductive approaches in our thematic analysis. Results In total, 306 labour situations were observed, and interviews were conducted with 16 physicians and 32 women who delivered by CS (16 emergency CS; 16 elective CS). In 92.5% of observations of physician–patient communication in the context of labour situations, the OPTION5 mean scores were low (5–25 out of 100) for presenting options, patient partnership, describing pros/cons, eliciting patient preferences and integrating patient preferences. Interviews found that non-clinical factors prime both physicians and patients in favour of CS prior to the clinical encounter in which the decision to perform a CS is documented. These interactions were both minimal in content and limited in purpose, with consent being an artefact of a process involving little communication. Conclusions Insufficient communication between physicians and patients is one of many factors driving increasing rates of caesarean section in Bangladesh. While this single clinical encounter provides an opportunity for practice improvement, interventions are unlikley to impact rates of CS without simultaneoulsy addressing physician, patient and health system contextual factors too.

Nurse-led research and innovation is key to improving health experiences and outcomes and reducing health inequalities. Clinical academic training programmes for nurses to develop research and innovation skills alongside continued development of their clinical practice are becoming increasingly established at national, regional and local levels. Though widely supported, geographical variation in the range and scope of opportunities available remains. It is imperative that clinical academic opportunities for nurses continue to grow to ensure equity of access and opportunity so that the potential of nurse-led clinical academic research to improve quality of care, health experience and health outcomes can be realised. In this paper, we describe and report on clinical academic internship opportunities available to nurses to share internationally, a range of innovative programmes currently in operation across the UK. Examples of some of the tangible benefits for patients, professional development, clinical teams and NHS organisations resulting from these clinical academic internships are illustrated. Information from local evaluations of internship programmes was collated to report what has worked well alongside 'real-world' set-up and sustainability challenges faced in practice. Clinical academic internship schemes are often opportunistically developed, making use of hybrid models of delivery and funding responsive to local needs and available resources. Key enablers of successful clinical academic internship programmes for nurses were support from senior clinical leaders and established relationships with local universities and wider organisations committed to research capacity building.

Most perinatal research relating to COVID-19 focuses on its negative impact on maternal and parental mental health. Currently, there are limited data on how to optimise positive health during the pandemic. We aimed to bridge this knowledge gap by exploring how women have adapted to becoming a new parent during the pandemic, and to identify elements of resilience and growth within their narratives. Mothers of infants aged under 12 weeks were recruited as part of a wider UK mixed-methods study. Semi-structured interviews with 20 mothers elicited data about how COVID-19 had influenced their transition to parent a new infant, and if and how they adapted during the pandemic, what strategies they used, and if and how these had been effective. Directed qualitative content analysis was undertaken and we used pre-existing theoretical frameworks of resilience and post-traumatic growth to analyse and interpret the data set. The findings show evidence of a range of resilience and post-traumatic growth concepts experienced during the pandemic in this cohort. Salient resilience themes included personal (active coping, reflective functioning, and meaning-making), relational (social support, partner relationships, and family relationships), and contextual (health and social connectedness) factors. There was also evidence of post-traumatic growth in terms of the potential for new work-related and leisure opportunities, and women developing wider and more meaningful connections with others. While further research is needed, and with individuals from diverse socioeconomic backgrounds, these findings emphasise the significance of social support and connectivity as vital to positive mental health. Opportunities to increase digital innovations to connect and support new parents should be maximised to buffer the negative impacts of further social distancing and crisis situations.

The failure to reduce maternal mortality rates in high-burden countries has led to calls for a greater understanding of structural determinants of inequities in access to maternal health services. Caste is a socially constructed identity that imposes structural disadvantage on subordinate groups. Although a South Asian construct, the existence of caste as structural social stratifier is actively rejected in Muslim Pakistan as a regressive symbol of Hinduism. In this inimical context, the possibility of caste as a driver of maternal health care inequities is not acknowledged, and has therefore remained unexplored in Pakistan. The objective of the present study is to quantitatively assess the variation in use of maternity services across different caste groups in Pakistan. The research also contributes to methodological innovation in modelling relationships between caste, mediating and/ or confounding socioeconomic factors and maternal health service indicators. A clustered, stratified survey sampled 1,457 mothers in districts Jhelum and Layyah. Multivariable, multilevel (confounder-adjusted) logistic regression analysis showed ‘Low’ caste mothers had higher odds of landlessness, no education, working in unskilled occupations, asset poverty, no antenatal care, and a home-based birth with an unskilled attendant compared to ‘High’/‘Middling’ caste individuals. Despite the important role of caste in patterning socio-economic disadvantage, its indirect causal effect on maternal health care was predominantly mediated through mothers’ education and household assets. Our findings suggest a need for group-specific policies, including constructing schools in low-caste dominant settlements, affirmative action with job quotas, redistributing agricultural lands and promoting industrial development in the poorer districts.

Introduction\ud Concerns about the impact of staffing shortages and burnout in the maternity workforce on safe and respectful care are longstanding, in the UK and internationally. The COVID 19 pandemic has further reduced workforce availability worldwide. We explored the impact of the pandemic on maternity staff experience.\ud Methods\ud We thematically analysed in-depth interviews (November 2020-October 2021) with 28 frontline maternity staff and 28 heads of service from seven geographically and demographically diverse NHS Trusts in England, as part of the ASPIRE COVID-19 study. \ud Results \ud The pandemic magnified existing problems within maternity care. Well established challenges such as short staffing, organisational demands, and barriers to providing relational care were exacerbated by the pandemic, leaving staff emotionally exhausted and unable to carry on. While the service is usually maintained through the goodwill of its workers, this is not sustainable in the long-term or through crises situations. We identified three sub-themes (figure 1) that capture changing experiences as the pandemic progressed.\ud \ud “A common goal against something bigger than yourself”: Tough, but all in it together\ud \ud A sudden influx of staff and resources early in the pandemic, combined with a sense of camaraderie, public support, and professional pride, led to an unexpectedly positive work environment. Despite fears for their own health and worries about taking home the virus to their families, many reported that making huge personal sacrifices was part of being \ud involved in something bigger than themselves.\ud \ud “There's only so much you can be pushed”: Loss of hope, meaning & value\ud \ud However, these protective factors did not last. Experiences later in the pandemic includedpoor staff recruitment and retention, deteriorating physical and psychological wellbeing, insufficient staffing and unmanageable workloads. Some described unsafe working practices such as an inability to provide one-to-one care in labour, and excessively long \ud working hours. Many described the emotional distress of working intensively to maintain standards of care but feeling only able to do the ‘bare minimum’. For some, the dissonance between the safe and personalised care they wanted to provide, and the \ud experience of dangerously low levels of staffing was associated with accounts of significant moral injury and distress.\ud \ud “I just can't do it anymore”: the tipping point of collapse\ud \ud Those interviewed later in 2021 reported increasingly critical staffing shortages. Respondents described compassion fatigue, both towards their colleagues, and for those in their care. “Exhausted”, “broken”, “unable to carry on”, or similar terms were used by a majority of participants. Serious concerns were raised about a rising incidence of burnout and breakdown, leading to an exodus of experienced and expert staff. One obstetrician warned of the “the biggest midwifery crisis of all time.”\ud \ud Conclusions\ud Our findings indicate that the COVID-19 pandemic has magnified the existing and escalating maternity staffing crisis in England, impacting on the ability to provide both safe and personalised care. International evidence suggests that maternity services globally face similar challenges.3 Coping mechanisms that usually enabled staff to go ‘above and \ud beyond’ to plug service gaps were breaking down towards the end of the data collection period, reducing the sustainability of all but basic care, and risking the psychological, emotional and physical health of respondents.\ud The impact of suboptimal staffing on service user safety is increasingly highlighted in maternity safety reviews, which have also recognised that whilst staff are frequently intensely concerned about staffing ratios, these concerns have been dismissed.\ud \ud Addressing insufficient staffing in maternity is a central recommendation of these reviews, which can no longer be ignored.\ud There is a unique opportunity for a post-pandemic rebuild of maternity services. This should begin by examining protective factors and organisational and political drivers that sustain psychological and physical staff wellbeing, and optimal service user outcomes and experiences. These include explicit organisational commitment to safe and sustainable staffing, flexible, autonomous practice, and protected time to provide person- centred, relational care. Getting these factors right may promote sustainable recruitment and retention of professional maternity care staff, both for care under normal circumstances, and for future crises.

Evidence-based policy toolboxes are essential for decision makers to effectively invest in and scale up maternal-child health and nutrition programs, and breastfeeding is no exception. This special issue focuses on the experiences implementing the Becoming Breastfeeding Friendly (BBF) toolbox in England, Scotland, and Wales. BBF is an initiative that includes a toolbox for decision making based on the Complex Adaptive System-based Breastfeeding Gear Model. The BBF initiative experience in Great Britain presented in this special issue illustrates how versatile BBF is as it can be readily adapted to the specific application context. In this instance one country, England was trained by the Yale School of Public Health team that developed BBF. England, in turn, trained and assisted Scotland and Wales with the implementation and oversight of BBF in those countries. The positive experience implementing BBF in Great Britain is fully consistent with findings related to this initiative in other countries with contrasting economic, social, political and health care systems; including Germany, Ghana, Mexico, Myanmar, and Samoa. In all instances BBF has led to breastfeeding policy improvements with strong implications for enabling breastfeeding environments including maternity benefits, workforce development, the Baby Friendly Hospital Initiative and behavior change communication campaigns. In conclusion, BBF is a powerful tool to help guide the effective scaling up of evidence-based programmes to advance breastfeeding protection, promotion and support globally.

Routine vaginal examinations are undertaken at regular time intervals during labour to assess whether labour is progressing as expected. Unusually slow progress can be due to underlying problems, described as labour dystocia, or can be a normal variation of progress. Evidence suggests that if mother and baby are well, length of labour alone should not be used to decide whether labour is progressing normally. Other methods to assess labour progress include intrapartum ultrasound and monitoring external physical and behavioural cues. Vaginal examinations can be distressing for women, and overdiagnosis of dystocia can result in iatrogenic morbidity due to unnecessary intervention. It is important to establish whether routine vaginal examinations are effective, both as an accurate measure of physiological labour progress and to distinguish true labour dystocia, or whether other methods for assessing labour progress are more effective. This Cochrane Review is an update of a review first published in 2013.To compare the effectiveness, acceptability, and consequences of routine vaginal examinations compared with other methods, or different timings, to assess labour progress at term.For this update, we searched Cochrane Pregnancy and Childbirth Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings) and ClinicalTrials.gov (28 February 2021). We also searched the reference lists of retrieved studies.We included randomised controlled trials (RCTs) of vaginal examinations compared with other methods of assessing labour progress and studies assessing different timings of vaginal examinations. Quasi-RCTs and cluster-RCTs were eligible for inclusion. We excluded cross-over trials and conference abstracts.Two review authors independently assessed all studies identified by the search for inclusion in the review. Four review authors independently extracted data. Two review authors assessed risk of bias and certainty of the evidence using GRADE.We included four studies that randomised a total of 755 women, with data analysed for 744 women and their babies. Interventions used to assess labour progress were routine vaginal examinations, routine ultrasound assessments, routine rectal examinations, routine vaginal examinations at different frequencies, and vaginal examinations as indicated. We were unable to conduct meta-analysis as there was only one study for each comparison. All studies were at high risk of performance bias due to difficulties with blinding. We assessed two studies as high risk of bias and two as low or unclear risk of bias for other domains. The overall certainty of the evidence assessed using GRADE was low or very low. Routine vaginal examinations versus routine ultrasound to assess labour progress (one study, 83 women and babies) Study in Turkey involving multiparous women with spontaneous onset of labour. Routine vaginal examinations may result in a slight increase in pain compared to routine ultrasound (mean difference -1.29, 95% confidence interval (CI) -2.10 to -0.48; one study, 83 women, low certainty evidence) (pain measured using a visual analogue scale (VAS) in reverse: zero indicating 'worst pain', 10 indicating no pain). The study did not assess our other primary outcomes: positive birth experience; augmentation of labour; spontaneous vaginal birth; chorioamnionitis; neonatal infection; admission to neonatal intensive care unit (NICU). Routine vaginal examinations versus routine rectal examinations to assess labour progress (one study, 307 women and babies) Study in Ireland involving women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine rectal examinations, routine vaginal examinations may have little or no effect on: augmentation of labour (risk ratio (RR) 1.03, 95% CI 0.63 to 1.68; one study, 307 women); and spontaneous vaginal birth (RR 0.98, 95% CI 0.90 to 1.06; one study, 307 women). We found insufficient data to fully assess: neonatal infections (RR 0.33, 95% CI 0.01 to 8.07; one study, 307 babies); and admission to NICU (RR 1.32, 95% CI 0.47 to 3.73; one study, 307 babies). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; maternal pain. Routine four-hourly vaginal examinations versus routine two-hourly examinations (one study, 150 women and babies) UK study involving primiparous women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine two-hourly vaginal examinations, routine four-hourly vaginal examinations may have little or no effect, with data compatible with both benefit and harm, on: augmentation of labour (RR 0.97, 95% CI 0.60 to 1.57; one study, 109 women); and spontaneous vaginal birth (RR 1.02, 95% CI 0.83 to 1.26; one study, 150 women). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; neonatal infection; admission to NICU; maternal pain. Routine vaginal examinations versus vaginal examinations as indicated (one study, 204 women and babies) Study in Malaysia involving primiparous women being induced at term. We assessed the certainty of the evidence as low. Compared with vaginal examinations as indicated, routine four-hourly vaginal examinations may result in more women having their labour augmented (RR 2.55, 95% CI 1.03 to 6.31; one study, 204 women). There may be little or no effect on: • spontaneous vaginal birth (RR 1.08, 95% CI 0.73 to 1.59; one study, 204 women); • chorioamnionitis (RR 3.06, 95% CI 0.13 to 74.21; one study, 204 women); • neonatal infection (RR 4.08, 95% CI 0.46 to 35.87; one study, 204 babies); • admission to NICU (RR 2.04, 95% CI 0.63 to 6.56; one study, 204 babies). The study did not assess our other primary outcomes of positive birth experience or maternal pain.Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for a safe and positive labour and birth, and if not, to develop an approach that does.

Background When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. Methods Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. Results Forty-two studies (published 1985–2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. Conclusions Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

Background and context. Breastfeeding peer support is valued and well-liked by women, but trials have not demonstrated efficacy in the UK. The ABA feasibility trial offered proactive peer support underpinned by behaviour change theory and an assets-based approach to women having their first baby, regardless of feeding intention. This paper explores viewsof women and infant feeding helpers (IFHs) of the ABA intervention. Setting and participants. Trained infant feeding helpers (IFHs) offered 50 women an antenatal meeting to discuss infant feeding and identify community assets in two English sites - one with a paid peer support service and the other volunteer-led. Daily contact was offered postnatally for the first 2 weeks after birth, followed by less frequent contact until 5 months.Methods. Interviews with 21 women and focus groups/interviews with 13 IFHs were analysed using thematic and framework methods.Results. Women talked positively about the antenatal meeting, mapping their network of support, receiving proactive contact from their IFH, keeping in touch using text messaging and access to local groups. The face-to-face antenatal visit facilitated the regular text-based communication both in pregnancy and in the early weeks after birth. Volunteer IFHs were more supportive of and enthusiastic about the intervention whereas most paid IFHs disliked some features of the intervention.Conclusions. Putting the ABA intervention into practice was challenging for some peer supporters. Despite this, breastfeeding rates may be improved by using a community assetsbased approach and focusing on infant feeding as an acceptable alternative to focusing on breastfeeding alone.

Objective Physiological length of labour is highly variable and population norms have low sensitivity and specificity for individuals. The birth history of mothers may provide a basis for personalized assessment of labour progress in their nulliparous daughters. This study was designed to investigate the relationship between length of labour in nulliparous daughters and in their mother's first birth, as a basis for constructing individualised labour prediction models in future. Study design A mother-daughter matched cohort study was conducted in two Israeli maternity hospitals. Recruitment took place between September 2014 and June 2015 via antenatal clinics. Inclusion criteria were nulliparous daughters with singleton pregnancies at ≥32 weeks' gestation and mothers of included daughters who had a first birth in hospital prior to 1997. Data were collected prospectively for daughters by questionnaire and from electronic hospital records, and through retrospective recall questionnaires for mothers. Mother-daughter length of labour data were analysed using parametric and non-parametric tests and logistic regression. Length of labour was categorized as ≤10 h and >10 h. Other factors influencing daughters' length of labour were also examined. Results Data from 323 mother-daughter pairs were analysed. Univariate logistic regression analysis showed that daughters of mothers who were in active labour for more than 10 h showed increased likelihood of having a longer labour [OR1.91 (95 % CI 1.19, 3.05, P = 0.007)]. Controlling for infant gender increased the effect size [OR3.23 (95 % CI 1.55, 6.74, P = 0.002)]. Multivariable logistic regression indicated that mothers' length of labour [OR1.88 (95 % CI 1.12, 3.17)] and daughters' age [OR1.08 (95 % CI 1.02, 1.14)], weight gain in pregnancy [OR1.10 (95 % CI 1.04, 1.16)] and use of anesthesia, were statistically significant factors for daughters' length of labour, with sensitivity, specificity, and positive and negative predictive values of 74 %, 56 %, 66 %, and 64 %, respectively. Conclusions A strong positive association between mother and daughter lengths of labour was found. A model that includes length of labour in their mother's first birth might be useful for labour progress prediction for nulliparous women. Practitioners could inquire about maternal first birth patterns as an additional heuristic to guide practice and increase precision in the clinical management of nullipara women's labour and delivery.

More women and neonates die each year in India than in almost every other country of the world. Since 1947, India has in principle provided free medical maternal health care to all pregnant and childbearing women. Although rates of maternal and neonatal deaths have fallen since the 1990s, major inequalities remain. Some Indian States have very high rates of interventions, (e.g., cesarean section), while others have intervention and care rates that are too low. Disrespectful treatment of women in labor and lack of evidence-based practice have also been reported. The World Health Organization and others have strongly recommended that professional midwives (trained in a woman-centered philosophy and to international standards) have a key role for reducing mortality and morbidity, minimizing unnecessary interventions in pregnancy and labor, and improving maternal care quality in low- and medium-income countries. This paper provides a community case-report of the first professional midwifery programme in India designed to international standards, implemented in 2011 in Hyderabad. We describe the design and implementation in the programme's first eleven years, as a basis for further scale-up and testing in India, and in other low- or medium-income countries. The ultimate aim is to improve maternal care quality, choice and outcomes in India and in similar socio-economic and cultural settings.

INTRODUCTION: Stillbirth is associated with significant physical, psychosocial and economic consequences for parents, families, wider society and the healthcare system. There is emerging momentum to design and evaluate interventions for care after stillbirth and in subsequent pregnancies. However, there is insufficient evidence to inform clinical practice compounded by inconsistent outcome reporting in research studies. To address this paucity of evidence, we plan to develop a core outcome set for stillbirth care research, through an international consensus process with key stakeholders including parents, healthcare professionals and researchers. METHODS AND ANALYSIS: The development of this core outcome set will be divided into five distinct phases: (1) Identifying potential outcomes from a mixed-methods systematic review and analysis of interviews with parents who have experienced stillbirth; (2) Creating a comprehensive outcome long-list and piloting of a Delphi questionnaire using think-aloud interviews; (3) Choosing the most important outcomes by conducting an international two-round Delphi survey including high-income, middle-income and low-income countries; (4) Deciding the core outcome set by consensus meetings with key stakeholders and (5) Dissemination and promotion of the core outcome set. A parent and public involvement panel and international steering committee has been convened to coproduce every stage of the development of this core outcome set. ETHICS AND DISSEMINATION: Ethical approval for the qualitative interviews has been approved by Berkshire Ethics Committee REC Reference 12/SC/0495. Ethical approval for the think-aloud interviews, Delphi survey and consensus meetings has been awarded from the University of Bristol Faculty of Health Sciences Research Ethics Committee (Reference number: 116535). The dissemination strategy is being developed with the parent and public involvement panel and steering committee. Results will be published in peer-reviewed specialty journals, shared at national and international conferences and promoted through parent organisations and charities. PROSPERO REGISTRATION NUMBER: CRD42018087748., National Institute of Health Research

Objectives: To explore stakeholders’ and national organisational perspectives on companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19, as part of the ASPIRE COVID-19 study. \ud Setting: Maternity care provision in England. \ud Participants: Interviews were held with 26 national governmental, professional, and service-user organisation leads (July-Dec 2020). Other data included public-facing outputs logged from 25 maternity Trusts (Sept/Oct 2020) and data extracted from 78 documents from eight key governmental, professional, and service-user organisations that informed national maternity care guidance and policy (Feb-Dec 2020). \ud Results: Six themes emerged: ‘Postcode lottery of care’ highlights variations in companionship and visiting practices between trusts/locations, ‘Confusion and stress around ‘rules’’ relates to a lack of and variable information concerning companionship/visiting. ‘Unintended consequences’ concerns the negative impacts of restricted companionship or visiting on women/birthing people and staff, ‘Need for flexibility’ highlights concerns about applying companionship and visiting policies irrespective of need, ‘‘Acceptable’ time for support’ highlights variations in when and if companionship was ‘allowed’ antenatally and intrapartum; and 'Loss of human rights for gain in infection control’ emphasizes how a predominant focus on infection control was at a cost to psychological safety and human rights. \ud Conclusions: Policies concerning companionship and visiting have been inconsistently applied within English maternity services during the COVID-19 pandemic. In some cases, policies were not justified by the level of risk, and were applied indiscriminately regardless of need. There is an urgent need to determine how to sensitively and flexibly balance risks and benefits and optimise outcomes during the current and future crisis situations. \ud \ud Strengths and limitations of this study\ud • This is the first paper to consider links between policy and practice in companionship and visiting in maternity care during the COVID-19 pandemic.\ud • Data triangulation across national level stakeholders in policy and practice and public facing Trust documentation provides nuanced and context related perspectives on why and how companionship and visiting was impacted. \ud • Stakeholders included national representatives from all key agencies involved in maternity care. \ud • Practice related issues were collected from 25 Trusts websites and social media-based public facing information, which may or may not reflect actual care practices. \ud • The paper focuses on antenatal and intrapartum care, with postnatal (including neonatal) care to be the focus of future publications.\ud • The study does not include information directly reported by parents or healthcare professionals.

The research team at South Warwickshire NHS Foundation Trust (SWFT) worked with the University of Central Lancashire (UCLan) on the ASPIRE (Achieving Safe and Personalised maternity care In Response to Epidemics) COVID-19 study. We conducted 55 stakeholder interviews to gain insight into the hospital's response to the pandemic. Working on the project presented many opportunities and challenges for us, including qualitative interviewing, using digital technology and engaging representative populations. This article, the fourth in the series, explains how the ASPIRE study gave us a unique opportunity to be part of a rare qualitative, midwifery-led research project which we fully embraced. We hope that this is the start of a new era of research that encourages midwife-led projects and qualitative studies.

Women usually conceptualize pregnancy as a normal physiological state. In contrast, formal maternity care provision tends to be focused on pathology and risk. The authors aim to explore the extent to which childbearing women apply a sickness lens to pregnancy. We have therefore examined antenatal problems spontaneously reported by 4,000 UK and Norwegian women who responded to the international social media-based Babies Born Better survey. We coded and classified the free-text comments of the respondents as either complaint or disease. We found striking differences in the rates and types of problems reported by the women. We discuss our findings by applying different perspectives of medicalization and of lay and biomedical knowledge.

Introduction\ud Many women experience giving birth as traumatic. Although women's subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research.\ud \ud Aim\ud To formulate a woman-centered, inclusive definition of a traumatic childbirth experience.\ud \ud Methods\ud After a rapid literature review, a five-step process was undertaken. First, a draft definition was created based on interdisciplinary experts’ views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback.\ud \ud Results\ud The stepwise process confirmed that a woman-centered and inclusive definition was important. The final definition was: “A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing.”\ud \ud Conclusions\ud This definition of a traumatic childbirth experience was developed through consultations with experts and consumer groups. The definition acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth. The women-centered and inclusive focus could help women to identify and validate their experiences of traumatic birth, offering benefits for practice, education, and research, as well as for policymaking and activism in the fields of perinatal mental health and respectful maternity care.

Most perinatal research relating to COVID-19 focuses on its negative impact on maternal and parental mental health. Currently, there are limited data on how to optimise positive health during the pandemic. We aimed to bridge this knowledge gap by exploring how women have adapted to becoming a new parent during the pandemic and to identify elements of resilience and growth within their narratives. Mothers of infants under the age of 4 months were recruited as part of a wider UK mixed-methods study. Semi-structured interviews with 20 mothers elicited data about how COVID-19 had influenced their transition to parent a new infant, and if and how they adapted during the pandemic, what strategies they used, and if and how these had been effective. Directed qualitative content analysis was undertaken, and pre-existing theoretical frameworks of resilience and post-traumatic growth (PTG) were used to analyse and interpret the data set. The findings show evidence of a range of resilience and PTG concepts experienced during the pandemic in this cohort. Salient resilience themes included personal (active coping, reflective functioning, and meaning-making), relational (social support, partner relationships, and family relationships), and contextual (health and social connectedness) factors. There was also evidence of PTG in terms of the potential for new work-related and leisure opportunities, and women developing wider and more meaningful connections with others. Although further research is needed, and with individuals from diverse socioeconomic backgrounds, these findings emphasise the significance of social support and connectivity as vital to positive mental health. Opportunities to increase digital innovations to connect and support new parents should be maximised to buffer the negative impacts of further social distancing and crisis situations.

In many high‐income countries such as the United Kingdom, inequalities in breastfeeding initiation and continuation rates exist, whereby socio‐economically advantaged mothers are most likely to breastfeed. Breastfeeding peer support interventions are recommended to address this inequality, with non‐profit breastfeeding organisations providing such support in areas of deprivation. As these organisations' roots and membership are often formed of relatively highly resourced women who have different backgrounds and experiences to those living in areas of deprivation, it is important to understand their practices in this context. In order to explore how UK non‐profit organisations practice breastfeeding peer support in areas of socio‐economic deprivation, a systematic review and meta‐ethnography of published and grey literature was undertaken. Sixteen texts were included, and three core themes constructed: (1) ‘changing communities’ reveals practices designed to generate community level change, and (2) ‘enabling one to one support’, explains how proactive working practices enabled individual mothers' access to supportive environments. (3) ‘forging partnerships with health professionals’, describes how embedding peer support within local health services facilitated peer supporters' access to mothers. While few breastfeeding peer support practices were directly linked to the context of socio‐economic deprivation, those described sought to influence community and individual level change. They illuminate the importance of interprofessional working. Further work to consolidate the peer‐professional interface to ensure needs‐led care is required.

In this chapter, the relation of salutogenesis to maternity care is discussed by giving a critical overview of studies in perinatal care, primarily measuring and promoting parental sense of coherence (SOC) and well-being.An overview is given on salutogenic approaches to neonatal and infant service provision. Important aspects of and salutogenic interventions for parent–child attachment in the first year of a child’s life are examined. Parents’ and caregivers’ relationship with their infants and newborns plays a critical role in shaping the emotional, cognitive, and social development of their child. Different interventions of early support to optimize parenting capacity and their impact are also discussed.Although the chapter focuses only on examples of salutogenic approaches based on reasonable evidence, there is a growing awareness of the value of salutogenic approaches to the provision of maternity care, and to facilities and services to enhance parenting and well-being in infancy and early childhood. Research gaps are identified, and suggestions for the direction of future research are outlined.

The World Conference of the International Society of Psychosomatic Obstetrics and Gynecology held in The Hague, Netherlands in October 2019 ran a dedicated session debating the global research prio...

Objective During pregnancy and childbirth, vulnerable and disadvantaged women have poorer outcomes, have less opportunities,face barriers in accessing care,and are at a greater risk of experiencing a traumatic birth. A recent synthesis of women's negative experiences of maternity care gathered data from predominantly low-income countries. However, these studies did not focus on vulnerable groups, and are not easily transferable into high-income settings due to differences in maternity care provision. The aim of this study was to synthesise existing qualitative literature focused on disadvantaged and vulnerable women's experience of maternity care in high-income countries. Methods A systematic literature search and meta-ethnographic methods were used. Search methods included searches on four databases, author run, and backward and forward chaining. Searches were conducted in March 2016 and updated in May 2020. Findings A total of 13,330 articles were identified and following checks against inclusion / exclusion criteria and quality appraisal 20 studies were included. Meta-ethnographic translation analytical methods were used to identify reciprocal and refutational findings, and to undertake a line of argument synthesis. Three third order reciprocal constructs were identified, ‘Prejudiced and deindividualized care’, ‘Interpersonal relationships and interactions’ and ‘Creating and enhancing insecurities.’ A line of argument synthesis entitled ‘I know my place’ encapsulates the experiences of disadvantaged and vulnerable women across the studies, acknowledging differential care practices, stigma and judgmental attitudes. A refutational translation was conceptualised as ‘Being seen, being heard’ acknowledging positive aspects of maternity care reported by women. Conclusion Insights highlight how women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision. Further research is needed to identify suitable care pathways for disadvantaged and vulnerable women and the development of suitable training to highlight negative attitudes towards these women in maternity care settings.

Background High numbers of women experience a traumatic birth, which can lead to childbirth-related post-traumatic stress disorder (CB-PTSD) onset, and negative and pervasive impacts for women, infants, and families. Policies, suitable service provision, and training are needed to identify and treat psychological morbidity following a traumatic birth experience, but currently there is little insight into whether and what is provided in different contexts. The aim of this knowledge mapping exercise was to map policy, service and training provision for women following a traumatic birth experience in different European countries. Methods A survey was distributed as part of the COST Action “Perinatal mental health and birth-related trauma: Maximizing best practice and optimal outcomes”. Questions were designed to capture country level data; care provision (i.e., national policies or guidelines for the screening, treatment and/or prevention of a traumatic birth, service provision), and nationally mandated pre-registration and post-registration training for maternity professionals. Results Eighteen countries participated. Only one country (the Netherlands) had national policies regarding the screening, treatment, and prevention of a traumatic birth experience/CB-PTSD. Service provision was provided formally in six countries (33%), and informally in the majority (78%). In almost all countries (89%), women could be referred to specialist perinatal or mental health services. Services tended to be provided by midwives, although some multidisciplinary practice was apparent. Seven (39%) of the countries offered ‘a few hours’ professional/pre-registration training, but none offered nationally mandated post-registration training. Conclusions A traumatic birth experience is a key public health concern. Evidence highlights important gaps regarding formalized care provision and training for care providers.

This is the first article in a series reflecting on the role of research midwives in the ASPIRE (Achieving Safe and Personalised maternity care In Response to Epidemics) study. In this article we introduce ASPIRE and provide an overview of the study. We also reflect on what makes ASPIRE uniquely midwifery-led within the National Institute for Health Research (NIHR) Portfolio and the role of research midwives within recruitment sites. We hope this article, and those that follow in the series, written by ASPIRE research midwives, will serve as a roadmap to inspire the next chapter of midwifery research in England.

The coronavirus (COVID-19) pandemic has resulted in rapid changes in many areas of health care worldwide.1 Some organisational and governance controls on innovation have been relaxed, to enable rapid adaptation to changing circumstances. The speed of innovation raises a range of ethical, governance and organisational issues. It is important to assess what changes have been instituted, which ones should be maintained, and how to encourage effective innovations in future. Maternity care provides an exemplar case within the broader health care setting, given the imperative to provide both safe and personalised care for optimal outcomes. Some pandemic-related changes in maternity services, such as restricting women’s opportunities for companionship during ultrasound scans or throughout labour, or limiting parental visiting to neonatal units, have been associated with psychological harm.2 Other changes provide more positive impacts, including reports of more individualised and efficient care associated with the increased use of telemedicine.3 We undertook a documentary analysis of national policy and service-user organisation responses to the pandemic in the United Kingdom (UK) and the Netherlands (NL), as part of the Achieving Safe and Personalised Maternity Care In Response to Epidemics (ASPIRE COVID-19) study. The overall aim of ASPIRE COVID-19 is to identify ‘what works’ in providing maternity care during the current and future pandemics, or similar health crises. The NL was chosen as the comparator to the UK because there were known differences in the organisation of maternity services during the COVID-19 pandemic between the two countries, especially for place of birth. Here we report on activities described as new or expanded innovations in 290 documents produced by seventeen key professional and service-user organisations in the NL and the UK between February and December 2020 (see Table 1). We included strategic papers, guidelines, protocols, and updates for health care professionals, such as newsletters.

Background Effective postnatal care is important for optimal care of women and newborns–to promote health and wellbeing, identify and treat clinical and psychosocial concerns, and to provide support for families. Yet uptake of formal postnatal care services is low and inequitable in many countries. As part of a larger study examining the views of women, partners, and families requiring both routine and specialised care, we analysed a subset of data on the views and experiences of women related to routine postnatal care. Methods We undertook a qualitative evidence synthesis, using a framework analysis approach. We included studies published up to December 2019 with extractable qualitative data, with no language restriction. We focused on women in the general population and their accounts of routine postnatal care utilization. We searched MEDLINE, PUBMED, CINAHL, EMBASE, EBM-Reviews, and grey literature. Two reviewers screened each study independently; inclusion was agreed by consensus. Data abstraction and scientific quality assessment were carried out using a study-specific extraction form and established quality assessment tools. The analysis framework was developed a priori based on previous knowledge and research on the topic and adapted. Due to the number of included texts, the final synthesis was developed inductively from the initial framework by iterative sampling of the included studies, until data saturation was achieved. Findings are presented by high versus low/middle income country, and by confidence in the finding, applying the GRADE-CERQual approach. Findings Of 12,678 papers, 512 met the inclusion criteria; 59 articles were sampled for analysis. Five themes were identified: access and availability; physical and human resources; external influences; social norms; and experience of care. High confidence study findings included the perceived low value of postnatal care for healthy women and infants; concerns around access and quality of care; and women’s desire for more emotional and psychosocial support during the postnatal period. These findings highlight multiple missed opportunities for postnatal care promotion and ensuring continuity of care. Conclusions Factors that influence women’s utilization of postnatal care are interlinked, and include access, quality, and social norms. Many women recognised the specific challenges of the postnatal period and emphasised the need for emotional and psychosocial support in this time, in addition to clinical care. While this is likely a universal need, studies on mental health needs have predominantly been conducted in high-income settings. Postnatal care programmes and related research should consider these multiple drivers and multi-faceted needs, and the holistic postpartum needs of women and their families should be studied in a wider range of settings. Registration This protocol is registered in the PROSPERO database for systematic reviews: CRD42019139183.

Midwife-led institutions, also called free-standing birth centres, offer birth assistance to women at low risk for complications. Free-standing birth centres, because they are the institutions that provide low intervention birth assistance, also present the possibility to conduct research on the skills and knowledge that are necessary to provide safe care for women who are at low risk for complications desiring an out-of-hospital birth. The aim of this study is to reveal the skills and knowledge necessary to provide care at low intervention births in free-standing birth centres in Germany for midwives post-certification. The theoretical and methodological standpoint of this study is hermeneutic phenomenology. In-depth qualitative methods will be used that are particularly sensitive to the research participants and their social context and allow for complexity, detail and context. The research sites are free-standing birth centres in Germany. Three strands of data will be collected. Each birth centre has its own quality management handbook. From this handbook, the chapter concerning the induction of new midwives will be analysed. Small focus groups will be held in ten birth centres throughout Germany; and data will be collected from 10 to 20 midwives during their induction period at the birth centre. The data collection methods will be open-ended interviews, data capture, journaling and non-participant observation with the new midwives. In-depth data analysis will reveal midwives’ experiences of skill acquisition in free-standing birth centres. The findings will be used to produce key recommendations for training midwives to work in birth centres.

In 1972, two landmark papers in this journal described the partograph,1,2 a chart designed to provide finite referral criteria for midwives working in peripheral clinics who needed to refer women in labour to Harare Hospital, Zimbabwe (then Rhodesia). This innovation coincided with influential reports from the National Maternity Hospital in Dublin of the ‘active management of labour’ (early amniotomy, proactive use of oxytocin and one‐to‐one nursing care) with the objective of achieving birth within a limited time frame.3 The partograph was globally adopted, and has been used as part of the assessment of labour progress for nearly half a century. It was recommended by the World Health Organization (WHO) in the early 1990s as a routine tool for displaying the progress of labour. Despite its global acceptance, utilization and correct completion rates as low as 31% and 3% respectively, have been reported.

Aim This study explored women's reasons for and their experiences of decision making that related to the phenomenon of freebirthing within the United Kingdom. Freebirthing is the active choice to birth without a health professional present, even where there is access to maternity care. Methods In total, 10 women were recruited to participate in an interpretative hermeneutic phenomenological study. Data were collected via written narratives and follow-up interviews. Findings The findings revealed direct implications for midwifery practice, namely that the complex and nuanced reasons to freebirth were often related to a previous birth trauma or negative interactions with maternity professionals. Additional findings revealed that women faced distressing opposition and conflict from midwives in relation to their decision to freebirth, despite its current legality in the United Kingdom. These findings have been published elsewhere. However, the purpose of this paper is twofold: first, using my research into freebirthing as a case study, I will demonstrate the use and benefits of interpretative hermeneutic phenomenology to midwifery and nursing research in order to generate knowledge for the benefit of service users, healthcare professionals, researchers and policy makers; second, I will discuss the activities I carried out to enhance dissemination and impact for the benefit of service users and clinicians.

Background\ud When Europe was hit by the COVID-19 pandemic, changes were made in maternity care to reduce infections. In Norway, hospital maternity wards, postnatal wards, and neonatal units’ companions and visitors were restricted. We aimed to explore the experiences of being pregnant, giving birth and becoming a parent in Norway during the COVID-19 pandemic.\ud \ud Methods\ud The study is based on the responses from women who provided in-depth qualitative accounts to the ongoing Babies Born Better survey version 3 during the first year of the COVID-19 pandemic. The responses were analysed with inductive thematic analysis.\ud \ud Results\ud In all, 806 women were included, regardless of parity and mode of birth. They gave birth in 42 of 45 available birthing units across Norway. The analysis resulted in four themes: 1) Pregnancy as a stressful waiting period; 2) Feeling lonely, isolated, and disempowered without their partner; 3) Sharing experiences and becoming a family; and 4) Busy postnatal care without compassion.\ud \ud Conclusion\ud The COVID-19 pandemic seems to have affected women's experiences of giving birth and becoming a parent in Norway. The restrictions placed on companionship by the healthcare facilities varied between hospitals. However, the restrictions seem to have affected a range of aspects related to women's experiences of late pregnancy, early labour and birth and the early postpartum period. Postnatal care was already poor, and the pandemic has highlighted the shortcomings, especially where companionship was banned.

Background: Parents of infants born premature and/or sick and who require neonatal care are at risk of poor mental health. Currently there is no comprehensive knowledge about interventions (i.e. types, evidence, resources) that have been exclusively designed to improve the psychosocial wellbeing of this population group. Purpose: To undertake a systematic scoping review of interventions focused on improving the psychosocial wellbeing of parents of sick/premature infants who required neonatal care to identify the: a) types of interventions, b) evidence of the interventions; and c) level of resources required to deliver the interventions. Search strategy: Following an initial pilot search, we searched seven databases (Medline, CINAHL, PsychInfo, Cochrane, Embase, Web of Science and Global Index), reviewed references and followed up key authors. Results: From 10516 hits, 38 papers met the inclusion criteria (36 different studies/interventions). Studies were categorised into creative oriented (11), group or peer support (4), relaxation or mindfulness (3), spiritual/religious (4), psychotherapeutic-based (11), and ‘other’ (3) (e.g. sleep, acupuncture). Most interventions had been undertaken in high-income settings with mothers and required varying levels of resources both within and between the different intervention types. While some interventions were effective, there was high heterogeneity with similar interventions using different designs, protocols and outcomes. Most intervention types included studies that highlighted what parents valued, e.g. self-care, relaxation, social opportunities. Implications for research: Evidence highlights a wide range of potential interventions for nursing and other specialist staff to consider and offers insights into potential mechanisms of effectiveness to underpin future intervention design.

Abstrait Contexte Les taux de césariennes sont en hausse dans toutes les régions du monde. Des taux très élevés dans certains groupes de femmes coexistent avec des taux très bas dans d’autres. Ces deux extrêmes sont associés à des conséquences négatives à court et à long terme. Ceci constitue un problème de santé publique majeur. Optimiser l’utilisation de la césarienne est crucial pour des soins de santé maternelle durables et de bonne qualité. En 2018, sur la base des recherches réalisées, l’Organisation Mondiale de la Santé a publié des recommandations d’interventions non-cliniques pour la réduction des césariennes non nécessaires. Ce guide a identifié des lacunes notables en matière de recherche et a appelé à la réalisation de recherches formatives avant la réalisation d’une intervention, afin de définir les déterminants locaux des naissances par césarienne et les facteurs qui pourraient affecter la mise en œuvre de stratégies d’optimisation multidimensionnelles. Ce protocole de recherche formative original a été créé comme un guide pour l’évaluation et la compréhension du contexte à l’attention de ceux qui prévoient d’agir pour optimiser l’utilisation de la césarienne. Méthodes Ce protocole de recherche formative inclut trois composantes principales: (1) une revue de la littérature; (2) une évaluation rapide de l’état de préparation; (3) une recherche qualitative initiale avec les femmes, les prestataires de soins de santé et les administratifs. La revue de la littérature et l’évaluation rapide de l’état de préparation incluent des outils pour la cartographie de la mise en œuvre de politiques locales, de protocoles, de pratiques et d’organisation des soins afin de décrire et d’évaluer le contexte avant toute mise en œuvre. La recherche qualitative est organisée en 12 interventions susceptibles de réduire les césariennes non nécessaires. Chaque intervention est conçue comme un « module » et comprend une description de l’intervention, des éléments de revue de la littérature, une théorie du changement, ainsi que des guides pour des entretiens approfondis et des discussions de groupe. Tous les outils d’études sont inclus dans ce protocole. Discussion Ce protocole original a été conçu pour venir en appui d’une recherche formative qui constitue une étape d’une recherche de mise en œuvre visant à une utilisation optimale de la césarienne. Nous encourageons les chercheurs, les responsables de politiques et les ministres de la santé à adopter et adapter ce protocole à leur contexte, ainsi qu’à partager et utiliser leurs résultats comme un catalyseur pour l’adoption rapide de mesures efficaces.

Background WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines. Methods WHO convened a writing group drawn from the technical teams involved in its recent (2010–2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Results We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding ‘research evidence’ sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health. Conclusions This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process. Electronic supplementary material The online version of this article (10.1186/s12961-019-0468-4) contains supplementary material, which is available to authorized users.

Social media is fast becoming a global phenomenon with recent research providing insight into the complex inter-weaving relationship between the media and women and families over the childbirth continuum. Additionally, a growing body of evidence demonstrates a major cultural shift in the agency and information-seeking practices of women through social media. This perhaps suggests that services fall short of providing real and lived value to the women navigating through maternity systems in the United Kingdom, due to changes in culture and society. A deeper understanding of this phenomenon may help providers and practitioners offer care which better supports women's needs and enable them to develop innovative new approaches for future service provision. The aim of this article is to examine the literature and develop a deeper understanding of how social media may impact upon women, childbearing and midwifery practice via six domains. In conclusion, informational, experimental, and relational needs of women could be enhanced with funding and investment into the role of new expert tech-midwives using social media initiatives within maternity systems. Thus, supporting the demands of modern technology use by woman to elevate midwifery care provision and satisfaction and protect against the technocratic and patriarchal influence of childbirth. This synthesis of the literature through a western cultural lens may also be relevant to an international audience.

Introduction Women can face opposition when exerting autonomous decision-making regarding their birth choices, particularly when the decisions involve going against medical advice and/or outside of national guidelines. Termed ‘unconventional birth choices’, some research has explored women’s reasons and experiences of making such choices, but less is known about the midwives caring for them. Objectives To synthesize existing qualitative literature on the views, attitudes, and experiences of midwives caring for women who make unconventional birth choices. Methods A systematic search and meta-ethnography informed by Noblit and Hare and Schutz was undertaken. Eight databases were searched using predetermined search terms, alongside author, reference, citation chasing, and hand searching. Searches were conducted in July 2016 and updated in October 2017. Qualitative studies published since 1993 in English were included. Included studies were subjected to quality appraisal, conducted independently by two reviewers. Analysis was informed by the interpretative meta-ethnography methods. Main results Five studies met the inclusion criteria. Eight subthemes emerged. These resulted in three higher level interpretative themes emerged: perceptions of women’s decision making, conflicting tensions as caregivers, ways of working with-woman. Conclusions Midwives can play a pivotal role in ensuring that respectful maternity care includes supporting women in their birthing decisions. Whilst limited research has been undertaken in this area, available insights suggest that midwives’ views in this area are situated along a spectrum from ‘willingly facilitative’ to ‘reluctantly accepting’. Views were influenced by context, as well as prior philosophies and values. While further research is needed, this study offers insights into the challenges women can face in seeking unconventional birth choices if they require support from midwives to do so.

Objective Our objectives were to study the association between epidural analgesia and risk of severe perineal laceration (SPL), and identify additional risk factors for SPL. This multicentre study consisted of an analysis of data from the MidconBirth Phase I Database, on the use of EA and perineal results during childbirth. (World Health Organization, International Clinical Trials Registry Platform, 2016: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN17833269). Methods We conducted a prospective study of pregnant women at term between July 2016 and July 2017 in 30 public maternity hospitals in Catalonia, Spain. Inclusion criteria were an uncomplicated singleton pregnancy, in cephalic presentation and vaginal birth. Data was analysed separately for instrumental births and spontaneous vaginal births, as the former is more frequently associated with episiotomy and more perineal lacerations. Risk factors as well as protective factors in each cohort of women (instrumental and spontaneous vaginal birth), were identified. Multivariate logistic regression model was performed to study the association between epidural analgesia and SPL to identify potential confounders. Odds ratios (OR), using 95% confidence intervals (CI) were constructed. Findings During the study period, 5497 eligible women gave birth, 77.46% of them received epidural analgesia. SPL occurred in 1.63% of births. The univariate analysis showed births with epidural analgesia had significantly higher rates of inductions, augmentation of labour, lithotomy position for birth and episiotomy. However, this association disappeared when the variable "type of vaginal birth" was introduced. In multivariate logistic regression, nulliparity was the major predictor for SPL (OR: 0.17; CI 95%: 0.08–0.34, p: 0.000). Key conclusions Epidural analgesia was not associated with SPL once confounding factors were included. Other interesting factors associated with SPL were identified. Implications for practice This paper identifies important practice areas which contribute to SPL and which have the potential to be rectified. It offers evidence on the role that EA plays on pelvic floor injuries and it adds to existing evidence about the disadvantages of using the lithotomy position for birth, especially in relation to SPL. It highlights the need for practice change in Catalonia from what can be considered a medical model of care to one more aligned with the midwifery philosophy of care through the development of clinical guidelines. It also signals the need to provide women with evidence base upon which to make informed choices on the use of EA, specifically in relation to SPL.

ObjectivesWe compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births.DesignWe used population linked data from New South Wales, Australia (2001–2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age.ResultsOf 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years.ConclusionIOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.

Purpose\ud This discussion article considers how an emotion-focused approach can be adopted to prevent psychological birth trauma and to optimize perinatal wellbeing for women and their families.\ud Conclusions\ud Emotion-focused approaches have a different perspective when compared to other classic psychotherapy methods. This approach may help women to resolve the negative impacts of psychological birth trauma; to prevent post-traumatic stress disorder onset; to lead to better results for mother and baby well-being; and may be cost effective.\ud Practice Implications\ud Mental health nurses/midwives should receive education about emotion-focused approaches in addition to gaining competence in basic counseling skills so that they can utilize these approaches with women.

Background During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers. Methods A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence. Results 31 papers, reporting on 27 studies and published 1985–2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised. Conclusion Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01146-3., Plain language summary During the late stages of childbirth, complications can occur which require rapid birth of the baby. This can be facilitated with instruments (usually forceps or a suction cup) or by surgery (caesarean section). In some circumstances, instrumental birth (also termed assisted vaginal delivery, AVD) may be a better option than caesarean section. AVD requires practitioners to develop skills, competence and expertise in the procedure. Our aim for this review was to examine practitioners’, funders’ and policy makers’ views about competence and expertise in AVD, how they can best gain this, the barriers and facilitators to implementing training packages, and their views, opinions and perspectives of their training. We included 27 studies (published 1985–2020), mostly from high-income countries. We had moderate confidence on one findings statement, with the rest assessed with low confidence. We found that practitioners valued extra training in AVD, observing others using the different instruments, and opportunities for clinical supervision, mentorship to gain experience, competence and expertise. We also found that, from the practitioners’ perspective, competence encompasses a number of inter-related skill sets; non-technical skills (e.g. effective communication with the labouring woman), broad clinical skills (e.g. capacity to assess the whole clinical picture) and technical instrumental skills (e.g. correct application of a vacuum cup to the fetal head, or capacity to turn the baby so it is in the right position). Practitioners also identified a number of barriers and facilitators that supported (or did not support) their training needs and development. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01146-3.

Background: In recent years, higher than the recommended rate of oxytocin use has been observed among low-risk women. This study examines the relationship between oxytocin administration and birth outcomes in women and neonates. Methods: A retrospective analysis of birth and neonatal outcomes for women who received oxytocin versus those who did not. The sample included 322 women with a low-risk pregnancy. Results: Oxytocin administration was associated with cesarean section (aOR 4.81, 95% CI: 1.80–12.81), instrumental birth (aOR 3.34, 95% CI: 1.45–7.67), episiotomy (aOR 3.79, 95% CI: 2.20–6.52) and length of the second stage (aOR 00:18, 95% CI: 00:04–00:31). In neonatal outcomes, oxytocin in labor was associated with umbilical artery pH ≤ 7.20 (OR 3.29, 95% CI: 1.33–8.14). Admission to neonatal intensive care unit (OR 0.56, 95% CI: 0.22–1.42), neonatal resuscitation (OR 1.04, 95% CI: 0.22–1.42), and Apgar score &lt, 7 (OR 0.48, 95% CI: 0.17–1.33) were not associated with oxytocin administration during labor. Conclusions: Oxytocin administration during labor for low-risk women may lead to worse birth outcomes with an increased risk of instrumental birth and cesarean, episiotomy and the use of epidural analgesia for pain relief. Neonatal results may be also worse with an increased proportion of neonates displaying an umbilical arterial pH ≤ 7.20.

To explore and describe what women who have given birth in Norway emphasise as important aspects of care during childbirth.The study is based on data from the Babies Born Better online survey, version 2.The maternity care system in Norway.Women who gave birth in Norway between 2013 and 2018.Descriptive statistics were used to describe sample characteristics and to compare data from the B3 survey with national data from the Medical Birth Registry of Norway. The open-ended questions were analysed with an inductive thematic analysis.Themes developed from two open-ended questions.The final sample included 8401 women. There were no obvious differences between the sample population and the national population with respect to maternal age, marital status, parity, mode of birth and place of birth, except for the proportion of planned home births. Four themes and one overarching theme were identified; Compassionate and Respectful Care, A Family Focus, Sense of Continuity and Consistency, and Sense of Security. Overarching theme: Coherence in Childbearing.Norwegian women across all birth settings emphasise maternity care that authentically focuses on both socio-cultural and psychological aspects of care, and physical and clinical factors. If the positive aspects of care identified in this study are adopted at all levels of the maternity care system and from all care providers, there is a high chance that most women will have a safe outcome, and a strong sense of coherence related to a positive birth and motherhood experience.Having a baby is a pivotal life changing experience and not just a clinical event, according to a survey of 8400 women in Norway. Positive birth and motherhood experiences depend on maternity staff who are both skilled and kind.